By Katie O’Leary.
Many Americans do not know the difference between Medicare and Medicaid. There are a lot of programs our country has created, many of them can be even more confusing and have even more paperwork to trip you up. Just qualifying for Medicare can be a headache: you can be denied multiple times, get the wrong information, and even have go to court to receive the benefits you so desperately need. Medicare is granted 2 years after SSDI is awarded. One cannot apply for it until one reaches the mandatory retirement age, depending on one’s year of birth, or 65, whichever comes first. If you are less than 65 and receive SSDI, one may be eligible for Medicaid depending on state income thresholds. It’s not a guarantee. Under certain conditions, say dual eligibility gained as an adult disabled child, one may be eligible for both Medicare and Medicaid. Rules and thresholds vary by state. When an American citizen turns 65 years of age, they automatically qualify for Medicare. But, if you have a disability, you can apply for Medicare and receive the same benefits at a younger age.
Such is the case with Sarah, a patient who qualified for Medicare after being approved for disability benefits due to her full-body CRPS. (We’ve changed her name so as not to hurt her attempts at finding a medical practice)
For those who do not know, CRPS (Complex Regional Pain Syndrome) is a disorder of the sympathetic nervous system, usually triggered by an injury, surgery, accident, etc. The brain becomes confused and believes that long after an injury to a particular part of the body has healed, that the area is in fact still damaged. This results in excruciating neuropathic pain signals being sent to that part of the body, or in Sarah’s case, her ENTIRE body. It started with an injury to her shoulder from a nasty fall at her job. Unfortunately, CRPS is known to spread, and hers has spread to her other limbs and her internal organs as well. She qualified for disability in 2015 after a worker’s compensation case and has been trying to find a decent clinic and doctor to treat her disorder.
On August 22, 2018, Sarah called the Mangrove Medical Group located in Chico, CA looking for a new doctor to potentially treat her. When she asked if they take Medicare patients, they informed her that they only take patients who are 65 and older. She immediately followed up with her Medicare representative who told her this was not true – Medicare patients cannot be discriminated against or denied coverage based on age. When Sarah dug deeper, the administrator for Mangrove asked her if she was a potential pain management patient. When Sarah said yes, the administrator said “We do not prescribe opioids so that is why we do not cover patients under 65.”
I was appalled by this statement. Denying coverage to disability patients because you do not wish to treat their pain? I had to find out for myself what was going on. And what I would soon find out, is that this is happening everywhere. I called Mangrove Medical Group and asked to speak to their administrator Ann.
“Do you accept Medicare patients?” I asked.
“Yes we do.” She said.
“What about patients under 65 years of age?” I said.
“At this time we don’t accept patients younger than 65.” She replied.
When I told her that I was a writer she immediately hung up on me and all further attempts to contact her were sent directly to voicemail.
I then decided to call Medicare myself and see what they would say about this situation. Could it be true that in this day and age, with the opioid epidemic rising, and with the influx of disability patients – that doctors could deny Medicare patients who are younger? Is this a new way to restrict pain patients from taking advantage?
“I have never heard of that happening before – ever.” This was said by Diana, in a tone of shock, a Medicare representative I spoke to and to whom I told Sarah’s story. She informed me that not only was this illegal, but that it violated the list of rights for all covered Medicare patients:
- Be treated with dignity and respect at all times.
- Be protected from discrimination. Every company or agency that works with Medicare must obey the law. They can’t treat you differently because of your race, color, national origin, disability, age, religion, or sex.
- Have your personal and health information kept private.
- Get information in a way you understand from Medicare, health care providers, and, under certain circumstances, contractors.
- Get understandable information about Medicare to help you make health care decisions (this list is available via medicare.gov)
Diana went on to tell me, “Notice how it says ‘be protected by discrimination’? It includes age. If a doctor had a MEDICAL reason to deny service or coverage to this patient, they would have to submit paperwork, or an ABN: ‘An Advance Beneficiary Notice (ABN), also known as a waiver of liability, is a notice a provider should give you before you receive a service if, based on Medicare coverage rules, your provider has reason to believe Medicare will not pay for the service (medicare.gov).’”
But Sarah did not receive an ABN. She was told over the phone that because she was under the age of 65, she would not be accepted as a patient at the Mangrove Medical Group. Diana then said, “She needs to file a complaint against this medical office with her local civil rights office: hhs.gov/hippa. They cannot deny her coverage based on her age. That is simply discrimination.”
I consulted Terri Lewis, Ph.D., a frequent contributor to the National Pain Report. When I asked Terri about this situation, she said, “The only way they could legitimately deny [this patient] is if they were not contracted on her insurance carrier plan. In this case, age, gender, disability are not involved. They do not have to participate in every Medicare plan.”
Terri then went on to explain something called “capitation.” In a capitated plan, often called Advantage plans, the insurer strikes an agreement with physicians to limit the numbers of persons they have to serve so as not to overly burden the economic formula for the physician reimbursement. Most physicians will not disclosure that they have hit their capitation limits when they tell patients they are not accepting new patients.
Furthermore, if they are accepting patients on the Medicare plan in question, then they must accept despite characteristics. If pain is in the equation they can say, “We do not treat pain.” But they must refer, and the insurer must make sure they have qualified providers for pain management on their plans. Unfortunately they can have qualified providers who are working at the limit of their capitation agreements who are not taking new Medicare patients under the plan in question. It’s a form of hidden rationing that remains undisclosed to the public. It harms patients who are complex.
A medical practice does not have to disclose capitation and could instead refer a patient to another practice. But in Sarah’s case, capitation does NOT seem to be present. They did not refer her to another doctor to treat her pain, and the economic burden of the medical practice is unclear given that they were accepting new patients. But the question I have is this: Wouldn’t it make more sense to just say they have too many patients and lie than admit to such discrimination? Most doctors usually shuffle patients to other doctors when they can’t provide a service or provide pain management due to lack of resources or simply from lack of ability. If this medical group is so ignorant and willing to reveal their discriminatory bias towards patients, and are willing to trample on the rights of patients – do they even know capitation is an option?
Ultimately, as a CRPS patient myself, I am appalled by the apparent actions of a medical group that is willing to break the law to deny service to patients with disabilities. If they wished to avoid becoming a pain management clinic, there are ways to do that without infringing upon patient rights. Sarah has already filed a complaint against Mangrove Medical Group. But I encourage every Medicare patient of ANY age to know your rights and to fight for them. You deserve treatment and you deserve to be heard. And for medical groups who are afraid of dealing with pain patients? There are other ways to avoid pain management as a specialty: it’s called not having it.
If you or a loved one feels that you are being discriminated against by a medical group, doctor, hospital, or health plan while on Medicare, please go to this website to file a claim as soon as possible: hhs.gov/hippa
Repeated attempts to further reach the Mangrove Medical Group were unsuccessful
 Her name has been changed to protect privacy of those involved
 Her name has been changed to protect the privacy of those involved
 All further attempts to reach the Mangrove Medical Group Administration office were unsuccessful and went to voicemail
 Her name was changed to protect the privacy of those involved